By Michael Ollove Stateline.org
WWR Article Summary (tl;dr) As Michael Ollove reports, the crisis has pushed many primary care practitioners, especially those in small, unaffiliated practices to the brink, threatening them with insolvency.
If Dr. Erica Swegler, a solo primary care doctor in Austin, Texas, hadn't gotten her bank to delay payments on one of the loans she had taken out to open her practice five years ago, she said, "I would have been out of business in April."
Likewise, she's sure she would have had to close if she hadn't also received a $36,000 federal Payment Protection Program coronavirus loan to carry her over a couple of months while her patients stayed away in droves. Ditto if Medicare and Medicaid hadn't relaxed rules to allow for compensation and better reimbursement rates for telehealth visits with patients, including telephone consultations.
Even with all that assistance, she said, "We're running a $10,000-a-month deficit, which isn't sustainable over any length of time."
In other words, she's still in trouble, even if patient medical visits have drifted back up to 80% of normal from a low of 30%. "I thought I was seeing a light at the end of a tunnel," she said, "but it wasn't. It was a train coming at me."
The pandemic has wreaked havoc on all levels of medicine, not least of which are primary care doctors, arguably the front line in trying to keep Americans healthy and out of hospitals. While many practices, primary care and otherwise, have seen business pick up significantly since the lows of March and April, few have come close to full recovery, which is perilous for practices that operate with low margins in the best of times.
The crisis has pushed many primary care practitioners, especially those in small, unaffiliated practices like Swegler's, to the brink, threatening them with insolvency.
Many admit to fears of being forced to abandon their independence, which they believe best serves their patients and communities, in favor of the stability coming from joining larger medical groups or health systems or selling their practices to equity interests.
"As it goes along, there will be more pressure on unaligned primary care practices to partner up with insurance, hospitals or like-minded colleagues," said Tom Banning, CEO of the Texas Academy of Family Physicians. "It's really going to be difficult for those practices to survive long term."
The Primary Care Collaborative, a nonprofit that advocates for primary care, and two partner organizations published the results of a survey conducted in late June: Forty% of primary care providers said they weren't sure they could stay open through August. More than a third said they were not prepared for COVID-19 surges or the fall flu season.
Dr. Christopher Crow, president of the Texas-based Catalyst Health Network, an organization of a thousand independent primary care doctors, said the network has received at least 600 calls from physicians since the pandemic began inquiring about joining. The network says it is able to provide savings and support services to member doctors through an economy of scale and negotiating power with insurers and pharmacies that small practices on their own can't achieve.
"They say to me, 'Oh my God, that's what I need. I don't see how I'll survive unless I'm connected to those kinds of services,'" Crow said.
Primary care is certainly not the only specialty suffering. Dr. David Smail, a surgeon in Beverly, Massachusetts, said the state's prohibition against elective surgery had reduced his patient volume between 75% and 80% from mid-March to mid-May with a commensurate loss of revenue. Those weren't patients waiting for cosmetic nose jobs, he said. "I was sitting on patients with breast cancer waiting. People who had gallbladder attacks after every meal, people with hernias."
Dr. David Hoyt, executive director of the American College of Surgeons, said surgeons had seen volumes of surgery drop by 70-80%. In a survey published by the group in June, one third of surgeons questioned said they were considering either shutting their practices or limiting business to patients whose insurance plans fully reimbursed for all surgical care.
"The consequences will be truly profound if we are not careful," Hoyt said. One of those consequences, he said, is further consolidation in medicine, which health policy experts generally agree would reduce patient access and drive up costs.
The merging of independent practices, particularly in primary care, into larger health or hospital systems didn't start with the pandemic, Banning said. The finances of primary care have always been tough, especially under a fee-for-service reimbursement system in which doctors are paid based on specific services and procedures rather than time spent with patients to comprehensively understand and address their health care needs.
"A major worry is the pandemic will accelerate or some would say complete a level of consolidation" that has been occurring for years, said Dr. Eric Schneider, a physician and senior vice president for policy and research with the Commonwealth Fund, a foundation that funds health policy research.
Independent doctors sound as if they have come through a whirlwind but are still far from steady on their feet.
"Every day is a new challenge because the situation seems to constantly change," said Dr. Mary Nguyen, who, with her physician husband, operates a practice in rural Texas about 30 miles west of San Antonio. "I never know what I'll find. Is it five patients today or 15? The schedule is different every day."
The stress, she said, is through the roof. "I worry about the mental health of my staff as well as myself and my husband."
Patient visits, even with expanded use of telemedicine, fell by about 50% after the onset of the pandemic, she said. "Revenues have been down month to month between 30 and 50%," she said. The number of visits started to climb in May and June, but with the recent surge of cases in Texas, she said, "our visits are going down again, slowly."
"A lot of patients didn't want to come to the office because they were scared," Nguyen said. "A lot thought we were closed when we weren't. A lot prefer to wait. Some are willing to do telemedicine. Others not."
She is staying afloat thanks in part to the rent she charges a couple of tenants in her clinic's building.
She received a Payment Protection Program loan of $117,000, which enabled her to continue to pay the staff, but that money is running out, with no sign from Washington that the program will be renewed. She has had trouble finding even basic sanitary supplies. "Right now, we're having problems finding disinfectant wipes," she said. "We are getting baby wipes and dipping them in alcohol."
Nguyen worries about her many patients who have chronic medical conditions such as diabetes and high blood pressure but cannot monitor their conditions without coming to the office for lab work or examinations.
Many of them, she said, are out of work because of the pandemic and rationing their medicines instead of taking them every day as prescribed.
"The temperature outside here is 105 degrees," she said. "They are thinking, 'Do I pay for utilities or do I pay for medication?' Health gets pushed back because the effects don't seem as immediate to them."
Elsewhere in Texas, Dr. Lane Aiena, who is in a six-doctor practice in Huntsville, said that after a steep drop in appointments, he is busier now than before the pandemic thanks to pent-up demand. But the early days were grim, no more so than after one of the clinic's nurses tested positive and he slept in his office for three nights while waiting for his own negative test result to arrive. He didn't want to chance bringing the infection home to his 1- and 3-year-old children or to his wife.